An HIT Moment with ... is a quick interview with someone we find interesting. Daniela Mahoney, RN is president and CEO of Healthcare Innovative Solutions of Seville, OH.
Hospitals are still struggling with implementation of CPOE. What are some lessons learned about how to do it right?
There are a few major areas in which hospitals typically fall short. These are the items that often do not make it into the vendor’s work plan.
- Understanding the true effort that will be necessary to successfully implement such transformation.
- The impact organizational culture has on the planning process and how the project will be operationalized.
- The focus is concentrated on physicians, and rightly so. However, a team of clinical resources is responsible for the execution of the orders. This clinical transformation is often not understood until after the implementation. Then the organization’s response becomes very reactive. You see a high number of unintended consequences that could have been easily prevented had the organization fully understood the impact CPOE has on the clinical teams.
- And, as surprising as it may sound, many vendors are still very young at implementing CPOE. It seems they are learning as they go.
These items are equally important. I go to any hospital assuming that the vendor understands their platform and knows how to configure their software and upload their master profiles with the necessary parameters. Most of the time this is true, especially with some of the big players (but not always with some of the other vendors).
However, if you are lucky enough to get a work plan from the vendor, you realize that it is all about the technical steps that must be executed. CPOE is about 15% technology (the easy part) and the rest is all about process, yet 100% of the tasks are typically technical or software related. There may be references regarding “analyze current workflows,” but if you have never done this, one is asking, “What exactly are we analyzing and from what perspective?”
Workflow analysis is not a new concept for us in healthcare because we seem to always try to improve, become more efficient, and provide safer care for patients. The larger the organization is, the more initiatives or “lean” teams they may have. However, most of the smaller, community-based hospitals have a steeper hill to climb.
How do we go about addressing some of these challenges? Remember that culture eats strategy every day. When we look at culture, we should think about it holistically as an organization. Then we should focus on the medical staff to truly understand what can be accepted, how we should present the value proposition to clinicians and physicians, and how to sometimes compromise since everyone has to give up something. I try to create value propositions around the patient. Placing the patient at the epicenter of the transformation puts a different light on the whys and hows.
Some vendors offer packaged / fixed fees implementations. Budgets are estimated, approved, and the implementation begins. All is good, but we learn that there were no allocations for contingencies or considerations for what else is going on when the planned live event is scheduled (as simple as Halloween and they cannot get the appropriate staff for support — it sounds funny, but it is true). If we pull nursing for support, who will bridge the gap for patient care? Should you plan for external agency staff for patient care? Do you trust that they will do a job that you will be satisfied with? After all, these are your patients and their satisfaction is very important.
Should you outsource the support instead? If you do so, will your staff be less proficient? In what budget are these hours accounted for? Have you budgeted for training? How about retraining? These packaged deals often offer a false sense of security that the vendor will take care of it. Well, let me be candid and say, “They will not.” You cannot go to sleep at night thinking that you have nothing to worry about. The vendor has their responsibilities, but you have yours. Be sure you understand what they are. It takes two to tango, and if you are not careful, toes will be stepped on.
We need to understand that the true effort is not just on the IT side. That part is the most predictable, but understanding the effort required for clinical transformation can be overwhelming, almost daunting, when we realize what it is. At that point, timelines are typically slipping (and some vendors have financial penalties if you not meet them). These days, you have to meet the political timelines set by CMS so the organization does not lose its opportunity to get the incentive dollars. Because of this, there is a fine balance on how much transformation can take place, so the implementation moves along, remains on track, and the appropriate redesign processes occur, making good clinical sense.
Sometimes this balance comes with experience, but perhaps following some general concepts, such as not letting perfection getting in the way of good, may still accomplish the goals. Avoid paralysis by analysis. Realize that the CPOE implementation has a clear beginning, but not an end. It is a continuous journey that will give you the opportunity to improve as long as you recognize this upfront and create a governance structure to allow for constant process improvement. These structures and efforts are typically not budgeted or accounted for upfront. Knowing that it will not be perfect on Day One, don’t cut this piece of the budget just because it may seem the most expendable at the time. It has to be, however, safe for the patient. There should be no compromise for this, but if we do not measure, it will be hard to know.
What are some of the best practices involved with supporting physicians using IT systems?
The best practices I have seen for supporting physicians are not all the same. The organizations that provide support to most adequately match the culture of their physicians and organization are the most successful. To think that cookie cutter methods will work best is simply naive. Managers and administrators know their physicians and culture better than outsiders and should provide support based on what is best for their organization.
It is important to gauge the perceptions of your physicians in order to hear them out prior to designing a support system. It is very likely that your interpretation of what it means to implement CPOE is totally different than a physician’s interpretation. Setting expectations and defining what is expected of everyone will most likely lead you to providing support that the physicians feel is adequate.
At the end of the day, however, I have not seen anything more effective than one-on-one support among a blend of other options such as peer to peer or using residents when possible. Physicians respond well to nurses and they are instrumental in propagation of physician adoption. It is essential to understand how physicians process data when they make decisions. Understanding their rounding process and patterns and the data they need will offer valuable insight into how much support is needed, where the support should be placed, and how to deal with less-frequent users.
As a nurse, do you think hospitals are placing the right emphasis on clinical IT to help nurses?
I am seeing variations on this front. The average age for a nurse is somewhere around 48 years young. Many hospitals, especially more rural community hospitals, are still intimidated by technology. I also think we deal with a generation that it is not always very receptive to change and CPOE is all about change. In the larger facilities, I do see more opportunities for the nurses to choose a clinical informatics ladder, and there are provisions to support training in this field.
My main concern, however, is that the industry is telling IT that CPOE is a clinical project and that it should be led by clinicians. We do form clinical teams and have nurses and sometimes physicians leading the implementations. Now what does a nurse know about project management? About meeting milestones, lead and lag time? The tools that we give them to execute the projects are not designed to be used by clinicians, so there is a lot of struggling. The new tools that support the implementation of CPOE need to support the thought process of clinicians, not of a PMI-certified IT project manager.
What privacy problems and solutions are you seeing?
The most common ones are related to users not logging off their devices and sharing of the passwords from physicians to their staff, especially since some are still struggling with entering their orders into a CPOE system. We do not have to deal with many security breaches outside of the basic incidents, where sometimes people may get access inadvertently to units they should not, or access is too restrictive.
We see more and more need to allow physicians access to the clinical systems using their own devices, especially the iPad. One of the most interesting solutions to privacy I have seen lately has been the option of using virtual desktops for physicians for remote access. The hospital still has to implement the VDI (Virtual Desktop Infrastructure) so I would definitely look at this solution closer from a cost and performance standpoint. This would give users essentially the same interface to the hospital regardless of what device they are accessing it from, including iPads. It also prevents users from saving data onto the local devices. Overall, in my experience, I think hospitals are doing a reasonable job around security.
What would you change about Meaningful Use to emphasize patient safety and benefits?
If I could change anything about the Meaningful Use criteria to emphasize patient safety and benefits, it would be to change the order and percentage in which some of the requirements have been placed relative to Stages 1-3. Implementing CPOE, along with the other main components like medication reconciliation and discharge instructions, requires a substantial transformation of clinicians’ workflows. The MU criteria, in their current state, do not promote a logical transformation of this workflow, thus negatively impacting patient safety and benefits.
Without going off on a tangent and getting too deep into the logic of the MU criteria, some of the simple changes I would make to the MU criteria would be to align the goals of the objectives so they make sense from a clinical perspective. How can you have CPOE where only medication orders are entered, and only on 30% of unique patients? From a technology perspective it may make sense, but from a physician workflow perspective, it will be chaotic. How will this be safer for the patients? Also, how can I build order sets if we do not entirely address what patients need? It is unfortunate that some organizations look at this and plan around it without thinking that CPOE will require a holistic approach. CPOE should be done for the right reasons, not just for meeting the CMS timeline.
Here is another interesting objective. “More than 50 percent of all patients who are discharged from an eligible hospital or CAH’s inpatient or emergency department (POS 21 or 23) and who request an electronic copy of their discharge instructions are provided it.” This is all great, but to do this, you need to have discharge instructions implemented on 100% of your patients. If you have not yet implemented this component, it will be challenging. This particular module cannot be phased in too easily and it is often underestimated what it would take to deploy.